Five-year Experience with Endovascular Aneurysm Repair without Fenestration for Pararenal Aortic Aneurysms: Clinical Efficacy, Reintervention Rates, and Cost-effectiveness Compared with Open Repair in High Deliberate-practice Volume Centers

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Although endovascular aneurysm repair (EVAR) affords more favorable perioperative and long-term survival than open surgical repair (OSR), approximately 50% of abdominal aortic aneurysms (AAAs) are anatomically unsuitable for EVAR using commercially available devices. Our goal was to gauge the extended use of devices for pararenal aneurysm compared with OSR. Primary end points were aneurysm-related survival, secondary intervention, and cost per quality-adjusted life-year (QALY). From 2002 to 2009, 1769 patients with AAA were seen at our unit, of which 92 had interventions for pararenal AAAs that were reported by radiology as unsuitable for EVAR: 54 had OSR, 38 had EVAR. Unsuitability for EVAR included no normal aortic neck, neck angle >90°, and neck thrombus >4 mm. The EVAR group was significantly older (74.5 vs 71.1 years, P = .034), with a significantly higher mean Society of Vascular Surgery comorbidity severity scores (P < .0001) and Kertai Customized Probability Indices (P = .05). Most endografts (83%) were 36-mm diameter, and the mean proximal diameter was 32 mm. All OSRs were done with a diagonally placed proximal clamp, preserving flow to the highest renal artery. The renal arteries were reimplanted in four cases and the internal mesenteric artery in one. The 5-year aneurysm-related survival rates were higher with EVAR (100%) compared with OSR (94.4%, P > .05), although this did not reach statistical significance. The 5-year freedom from secondary intervention was similar between EVAR (94.1%, [95% confidence interval [CI], 80.1%-98.8%]) and OSR (100%, P > .05). The 5-year all-cause survival was significantly reduced in the EVAR group (50.4%, 95% CI, 34%-66%.) vs OSR (80.4%, [95% CI, 66.9%-89.5%; P = .0279; h, 0.34 [95% CI, 0.12-0.94]). However, none of the deaths in the EVAR group were aneurysm-related. The 30-day morbidity (P < .0001), length of hospital stay (P < .0001), 5-year quality-adjusted time spent without symptoms of disease and toxicity of treatment (P < .01), and cost per QALY (P < .01) were all significantly reduced with EVAR compared with OSR. Endografts can be effectively used to treat difficult pararenal AAAs, with enhanced long-term aneurysm-related survival, cost-effectiveness, and quality of life, and with significantly reduced perioperative morbidity, mortality, and waiting time from diagnosis to treatment.